Self-Esteem and Perceived Stress in Schizophrenia and Bipolar Affective Disorder: A Comparative Study

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Comparative research between schizophrenia and bipolar affective disorder (BPAD) remains sparse, particularly in Indian settings. We investigated whether self-esteem and stress perception differ between the two conditions. Eighty patients in partial remission (40 per diagnosis) were recruited from a tertiary psychiatric facility in India. Participants completed the Rosenberg Self-Esteem Scale and Perceived Stress Scale. Results Schizophrenia patients showed markedly lower self-esteem (mean 18.45 vs 22.80; t=3.45, p<0.001, d=0.77) and higher stress (mean 28.65 vs 23.10; t=3.82, p<0.001, d=0.86) than BPAD patients. Self-esteem and stress correlated strongly in schizophrenia (r=-0.58) and moderately in BPAD (r=-0.42). Women reported worse outcomes across both groups. Clinical Implications Schizophrenia patients demonstrate persistent psychological vulnerability during remission. Integrating routine screening for self-esteem and stress difficulties with psychosocial interventions targeting self-worth and stress management alongside pharmacological treatment may enhance outcomes in schizophrenia. self-esteem perceived stress schizophrenia bipolar disorder comparative study Introduction Managing a serious psychiatric disorder involves far more than simply controlling symptoms. People confronting schizophrenia or bipolar disorder face fundamental questions: Who am I? What can I actually do? Where do I fit in? Two particular aspects of the human experience matter greatly here: how people see and value themselves, and how burdened they feel by life's demands. 1 , 2 While both schizophrenia and BPAD rank among the most challenging psychiatric conditions, they unfold quite differently. Yet precisely how these two illnesses differ in their psychological impacts, particularly around self-regard and stress experience, remains unclear. 3 , 4 A person's self-esteem fundamentally shapes their psychological functioning and coping abilities. 5 , 6 , 7 It acts simultaneously as a shield against emotional pain and as a barometer of cumulative harm from disability, discrimination, and marginalisation. 8 , 9 Stress perception operates similarly; it predicts who will relapse, require hospitalisation, and ultimately thrive or struggle in their recovery. 10 , 11 Research hints that these two conditions create distinctly different patterns. Schizophrenia appears to erode self-worth persistently and deeply, particularly through internalised shame, persistent negative thinking patterns, and cognitive difficulties. 12 , 13 , 14 Bipolar disorder, by contrast, produces volatility; people often feel capable and worthy during elevated moods but devastated during depressive phases. 15 , 16 , 17 Stress similarly operates differently: schizophrenia generates ongoing hypervigilance and vulnerability, 18 , 19 , 20 whereas bipolar stress is more episodic and triggered by specific events like loss or achievement. 21 , 22 , 23 Surprisingly, most comparative work comes from Western countries 24 , 25 , 26 where individualistic cultures and well-resourced healthcare systems shape both illness experience and intervention access. In Asian contexts, particularly India, family interdependence, collectivist values, and pervasive mental health stigma fundamentally alter how self-worth and stress manifest and are managed. Moreover, existing Asian literature on severe mental illness predominantly examines quality of life, functional outcomes, or caregiver burden, with minimal attention to self-esteem and perceived stress as distinct psychological constructs. 3 , 27 , 28 , 29 , 30 Given that these constructs predict relapse, treatment adherence, and recovery trajectories, their systematic comparison between schizophrenia and BPAD in Indian settings remains critically under-examined. Understanding disorder-specific psychological vulnerabilities in this context is essential for designing feasible, culturally attuned psychosocial interventions within resource-limited mental health services. We designed this study to directly compare self-esteem and stress experiences between schizophrenia and BPAD in an Indian tertiary psychiatric setting. Methods Design and Setting This cross-sectional comparative study was conducted at a tertiary psychiatric facility serving predominantly rural populations in northern Karnataka, India. Data collection occurred between September 2024 and February 2025. Participants We recruited 80 patients, 40 diagnosed with schizophrenia (ICD-11: 6A20) and 40 with bipolar I disorder (ICD-11: 6A60). 31 All were in partial remission, meaning acute symptoms had subsided, but complete recovery had not occurred. Inclusion required: confirmed diagnosis through clinical evaluation and medical records; age 18 years or above; willingness to participate. We excluded patients with comorbid substance dependence (except tobacco), organic brain disorders, or cognitive impairment preventing meaningful participation. Convenience sampling was used; we approached eligible patients during their inpatient stay until reaching our target numbers. Measures: Rosenberg Self-Esteem Scale (RSES): 7 A 10-item Guttman scale assessing global self-esteem. Responses range from "strongly agree" to "strongly disagree." Scores are combined using a specific algorithm, yielding three categories: 25 (high self-esteem). Perceived Stress Scale (PSS): 10 , 32 A 10-item instrument measuring subjective appraisals of stress over the past month. Scores range 0–40, categorised as low (0–13), moderate ( 14 – 26 ), or high ( 27 – 40 ). Scale for Assessment of Positive Symptoms (SAPS): 33 Evaluated positive symptom severity in schizophrenia across hallucinations, delusions, bizarre behaviour, and formal thought disorder. Young Mania Rating Scale (YMRS): 34 An 11-item scale assessing manic symptoms in BPAD patients. Demographic proforma: Collected age, gender, education, occupation, marital status, and illness-related variables. Procedures: Ethical approval was obtained from the institutional ethics committee (reference withheld for blind review). Trained research assistants administered assessments individually in private settings following written informed consent. Diagnoses were confirmed via clinical evaluation and medical records documentation. Statistical Analysis: Descriptive statistics characterised the sample. Independent samples t-tests compared self-esteem and perceived stress between groups. Pearson correlations examined relationships between self-esteem and stress within each diagnostic group. Preliminary analyses controlled for age, gender, and illness duration. Significance was set at p < 0.05. Results Sample Description Table 1 summarises participant characteristics. The groups were similar on most variables. One notable difference: more BPAD patients fell in the younger age bracket (95% aged 15–47 years versus 80% of schizophrenia patients; χ²=4.11, p = 0.043). Both groups were predominantly rural (86% overall), Hindu (89%), and had limited formal education (only 9% held degrees). Most worked as farmers or daily wage labourers. The majority lived with family members. Table 1 Participant Characteristics Variable Schizophrenia (n = 40) BPAD (n = 40) p Female 24 (60%) 18 (45%) 0.18 Age 15–47 years 32 (80%) 38 (95%) 0.04* Rural Residence 35 (88%) 34 (85%) 0.75 No formal Education 11 (28%) 12 (30%) 0.44 *p < 0.05 Main Findings The primary results were striking. Schizophrenia patients reported substantially lower self-esteem than bipolar patients (mean 18.45 versus 22.80; t = 3.45, p < 0.001). The effect size was large (Cohen's d = 0.77). Nearly three-quarters of schizophrenia patients (72.5%) fell in the low self-esteem range, compared with just over half (52.5%) of bipolar patients. (See Table 2 for detailed self-esteem and stress comparisons.) Stress showed the reverse pattern. Schizophrenia patients experienced significantly more perceived stress (mean 28.65 versus 23.10; t = 3.82, p < 0.001). Again, the effect was large (d = 0.86). Almost nine in ten schizophrenia patients (87.5%) reported moderate-to-high stress, versus two-thirds (65%) of bipolar patients. Women fared worse in both diagnostic groups. Female schizophrenia patients scored lower on self-esteem (mean 16.83 versus 20.94 for males; p = 0.01) and showed similar patterns in BPAD. Table 2 Self-Esteem and Stress by Diagnosis Measure Schizophrenia BPAD t p d Self-esteem 18.45 (5.32) 22.80 (5.18) 3.45 < 0.001 0.77 Perceived stress 28.65 (6.42) 23.10 (7.15) 3.82 < 0.001 0.86 Note: Values are mean (SD). t = t-test statistic; p = p-value (significance level); d = Cohen's d (effect size). All comparisons were statistically significant at p < 0.001. Effect sizes (d ≥ 0.77) indicate large clinical differences between groups. Relationship Between Self-Esteem and Stress Self-esteem and stress were inversely related in both groups; lower self-worth accompanied higher stress. This correlation was strong in schizophrenia (r=-0.58, p < 0.001) and moderate in BPAD (r=-0.42, p < 0.05). The associations held after adjusting for age and gender. (See Table 3 for correlation data.) Table 3 Self-Esteem and Stress Correlation Group r p Schizophrenia -0.58 < 0.001 BPAD -0.42 < 0.05 Note: r = Pearson correlation coefficient (ranges from − 1 to + 1; negative values indicate inverse relationships). p = probability value indicating statistical significance (p < 0.05 indicates the relationship is unlikely to be due to chance). Secondary Analyses: Educational attainment showed protective effects in both groups: individuals with secondary or higher education reported higher self-esteem and lower stress compared to those with primary education only (schizophrenia t = 2.87, p < 0.01; BPAD t = 2.15, p < 0.05). Illness duration demonstrated no significant correlations with either outcome, contrary to expectations. Symptomatic severity (SAPS total scores in schizophrenia, YMRS in BPAD) showed moderate negative associations with self-esteem in schizophrenia (r = -0.44, p < 0.01) but weak associations in BPAD (r = -0.18, p = 0.26). Discussion This comparative study documents significant psychological disparities between schizophrenia and BPAD in cross-sectional remission states. Individuals with schizophrenia experienced markedly lower self-esteem and elevated perceived stress compared to those with BPAD. These differences appear robust, with large effect sizes, and persist after controlling for sociodemographic variables. 24 , 25 Self-Esteem: A Trait Marker in Schizophrenia: The pronounced self-esteem deficits in schizophrenia align with literature indicating that low self-regard operates as a trait-like vulnerability in this disorder. 9 , 35 , 14 This pattern may reflect the cumulative impact of persistent cognitive impairment, prominent negative symptoms, and chronic internalised stigma. 12 , 13 , 36 The correlation between symptom severity and self-esteem, observed in this study, suggests that residual symptoms maintain self-worth erosion even during partial remission. 33 By contrast, BPAD patients, despite comparable illness severity, retained relatively better preserved self-esteem. 15 , 37 This difference may reflect the episodic nature of BPAD, wherein periods of euthymia allow for psychological recovery and renewed self-affirmation. 38 , 39 The observed mood-linked variations in self-esteem (higher during euthymia compared to historical manic or depressive phases) support this interpretation. 40 , 17 Perceived Stress: Chronic vs. Episodic The heightened stress perception in schizophrenia is consistent with the diathesis-stress framework, wherein genetic vulnerability interacts with environmental adversity to maintain psychosis risk. 41 , 18 , 19 Our participants, despite remission status, continued to report chronic stress, suggesting that stress sensitivity persists as a neurobiological and psychological feature of schizophrenia. 3 The lower stress in BPAD, even with comparable clinical impairment, may reflect different mechanisms. 21 , 22 BPAD stress often co-varies with mood state; individuals in euthymic remission may experience reduced acute stressors and heightened coping capacity. 11 , 38 Moreover, the polarity-specific stress sensitivity in BPAD, whereby stress type (loss vs. achievement) determines episode polarity, may result in more contextually determined stress patterns compared to the global hyperarousal observed in schizophrenia. 21 , 23 , 42 Gender Considerations: Female participants across both groups reported lower self-esteem and higher stress. 24 This finding resonates with broader literature on gender disparities in mental health and reflects potentially compound effects of illness stigma, gender role expectations, and social marginalisation. 13 , 36 In India's sociocultural context, the intersection of psychiatric illness with gendered expectations may intensify self-devaluation and stress in women. 3 , 27 , 29 Clinical Implications: These findings underline the necessity for disorder-specific interventions. 24 , 14 , 38 For schizophrenia, integrating self-esteem enhancement into standard care via narrative therapy, identity work, or strengths-based approaches may yield significant benefits. 43 Addressing internalised stigma, as a key mediator of low self-esteem, warrants particular emphasis. 13 , 9 , 36 Similarly, stress management interventions, targeting both neurobiological dysregulation (via supported coping strategies) and psychosocial stressors (via family work or environmental modification), appear critical. 11 , 28 , 38 For BPAD, whilst self-esteem appears relatively less compromised, interventions should target the instability and contingency of self-worth, particularly the reliance on external achievement for self-validation. 37 , 16 Psychoeducation emphasising mood variability and its impact on self-appraisals may enhance psychological insight and reduce episode precipitation. 38 , 39 Implications for Asian Mental Health Services These findings carry particular significance for mental health service delivery in Asian settings, where resource constraints necessitate prioritising high-yield, low-cost interventions. Self-esteem and perceived stress assessments require minimal training, no specialized equipment, and can be administered by psychiatric social workers or nurses within existing consultation frameworks. Our data suggest that routine screening for these constructs during outpatient follow-ups could identify schizophrenia patients at heightened risk for relapse or disengagement, enabling targeted allocation of limited psychosocial resources. In India's context, where mental health services remain concentrated in tertiary centres with high patient volumes and limited counselling capacity, brief self-esteem and stress assessments offer a pragmatic triage mechanism. Furthermore, the gender disparities observed, with women reporting worse outcomes across both disorders, underscore the need for interventions that explicitly address the intersection of mental illness stigma with gendered social roles in South Asian families. Family psychoeducation programmes emphasizing these psychological vulnerabilities, rather than symptom management alone, may prove more culturally acceptable and effective in collectivist societies. Limitations: This study was cross-sectional, preventing causal inference. Convenience sampling may introduce selection bias. The PSS and RSES, developed in Western contexts, may not fully capture culturally specific expressions of stress and self-worth in Indian populations. 44 Future longitudinal, multisite studies incorporating qualitative methods and culturally adapted instruments would strengthen findings. Conclusion Individuals with schizophrenia experience significantly compromised self-esteem and heightened perceived stress relative to those with BPAD, even during comparable remission states. These psychological vulnerabilities warrant integrated attention within clinical care frameworks. Routine assessment of self-esteem and stress, coupled with targeted psychosocial interventions, offers promise for enhancing resilience and recovery outcomes in schizophrenia. The findings underscore the value of comparative approaches in unmasking disorder-specific psychological mechanisms and informing tailored, person-centred mental health care. Declarations Declaration of Interest None. Funding This research received no specific grant from any funding agency. Author Contribution Author 1 conceived and designed the work, acquired, analysed, and interpreted the data, and drafted the manuscript. Author 2 conceived and designed the work and provided critical revision of the manuscript for intellectual content. Author 3 conceived and designed the work, provided critical revision of the manuscript for intellectual content, and gave final approval. All authors have approved the final manuscript. Ethics Statement All procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2013. Ethical approval was obtained from the Institutional Ethics Committee (Ref: [withheld for blind review]). Consent Statement Written informed consent was obtained from all participants. Clinical trial number: not applicable Data Availability The datasets generated during the current study are available from the corresponding author upon reasonable request, subject to ethical approval. Transparency Declaration The lead author affirms that this manuscript provides an honest, accurate, and transparent account of the study. No important aspects have been omitted. Thesis Disclosure This research was completed as part of the first author's MPhil dissertation at a tertiary psychiatric institution in India. References The World Health Organization. Mental health. 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Encyclopedia of Behavioral Medicine .; 2013. doi:10.1007/978-1-4419-1005-9 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9289386","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":628889652,"identity":"84cc2ea5-653f-40ec-be60-98f311fa09ff","order_by":0,"name":"Monisha G","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYJCCA4wNDAz88u8fPgByePiI1iLZkMNsANLCRpQ1IC0GDTlsEiAOQS267b0HD/7cYWe3geHsscqvOXYybAzMDx/dwKPF7My5hMO8Z5KTtzP2pd2W3ZYMdBibsXEOPi03cgwOM7YxJ1s2M5jdltzGDNTCwyZNSMvBn231yQbHGMyKJbfVE6flAG/bYTuDMzxmjB+3HSZCy5kzBod5244nSM5gS5Zm3Hach42ZkF+O9xh//NlWbc8vwXzw489tQAZ788PH+LTAQGIDkGDmATGZiVAOAvYggvEHkapHwSgYBaNgZAEAQHxLXukB8dIAAAAASUVORK5CYII=","orcid":"","institution":"Dharwad Institute Of Mental Health And Neurosciences","correspondingAuthor":true,"prefix":"","firstName":"Monisha","middleName":"","lastName":"G","suffix":""},{"id":628889654,"identity":"cad83d97-776b-44f2-858f-0a3663b1ed2c","order_by":1,"name":"Rakesh NS","email":"","orcid":"","institution":"Dharwad Institute Of Mental Health And Neurosciences","correspondingAuthor":false,"prefix":"","firstName":"Rakesh","middleName":"","lastName":"NS","suffix":""},{"id":628889657,"identity":"9c2bc1a4-9850-4812-8b3c-1d6922b5c0ea","order_by":2,"name":"Anantharamu BG","email":"","orcid":"","institution":"Dharwad Institute Of Mental Health And Neurosciences","correspondingAuthor":false,"prefix":"","firstName":"Anantharamu","middleName":"","lastName":"BG","suffix":""}],"badges":[],"createdAt":"2026-04-01 09:08:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9289386/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9289386/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108490758,"identity":"a2a715e2-614d-4b6b-afc3-0fb8a2397ba0","added_by":"auto","created_at":"2026-05-05 09:48:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":268525,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9289386/v1/be868e1e-972a-41cc-aefd-380b1eb6761a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Self-Esteem and Perceived Stress in Schizophrenia and Bipolar Affective Disorder: A Comparative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eManaging a serious psychiatric disorder involves far more than simply controlling symptoms. People confronting schizophrenia or bipolar disorder face fundamental questions: Who am I? What can I actually do? Where do I fit in? Two particular aspects of the human experience matter greatly here: how people see and value themselves, and how burdened they feel by life's demands.\u003csup\u003e1\u003c/sup\u003e,\u003csup\u003e2\u003c/sup\u003e While both schizophrenia and BPAD rank among the most challenging psychiatric conditions, they unfold quite differently. Yet precisely how these two illnesses differ in their psychological impacts, particularly around self-regard and stress experience, remains unclear. \u003csup\u003e3\u003c/sup\u003e,\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA person's self-esteem fundamentally shapes their psychological functioning and coping abilities.\u003csup\u003e5\u003c/sup\u003e,\u003csup\u003e6\u003c/sup\u003e,\u003csup\u003e7\u003c/sup\u003e It acts simultaneously as a shield against emotional pain and as a barometer of cumulative harm from disability, discrimination, and marginalisation.\u003csup\u003e8\u003c/sup\u003e,\u003csup\u003e9\u003c/sup\u003e Stress perception operates similarly; it predicts who will relapse, require hospitalisation, and ultimately thrive or struggle in their recovery.\u003csup\u003e10\u003c/sup\u003e,\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eResearch hints that these two conditions create distinctly different patterns. Schizophrenia appears to erode self-worth persistently and deeply, particularly through internalised shame, persistent negative thinking patterns, and cognitive difficulties.\u003csup\u003e12\u003c/sup\u003e,\u003csup\u003e13\u003c/sup\u003e,\u003csup\u003e14\u003c/sup\u003e Bipolar disorder, by contrast, produces volatility; people often feel capable and worthy during elevated moods but devastated during depressive phases.\u003csup\u003e15\u003c/sup\u003e,\u003csup\u003e16\u003c/sup\u003e,\u003csup\u003e17\u003c/sup\u003e Stress similarly operates differently: schizophrenia generates ongoing hypervigilance and vulnerability,\u003csup\u003e18\u003c/sup\u003e,\u003csup\u003e19\u003c/sup\u003e,\u003csup\u003e20\u003c/sup\u003e whereas bipolar stress is more episodic and triggered by specific events like loss or achievement.\u003csup\u003e21\u003c/sup\u003e,\u003csup\u003e22\u003c/sup\u003e,\u003csup\u003e23\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSurprisingly, most comparative work comes from Western countries\u003csup\u003e24\u003c/sup\u003e,\u003csup\u003e25\u003c/sup\u003e,\u003csup\u003e26\u003c/sup\u003e where individualistic cultures and well-resourced healthcare systems shape both illness experience and intervention access. In Asian contexts, particularly India, family interdependence, collectivist values, and pervasive mental health stigma fundamentally alter how self-worth and stress manifest and are managed. Moreover, existing Asian literature on severe mental illness predominantly examines quality of life, functional outcomes, or caregiver burden, with minimal attention to self-esteem and perceived stress as distinct psychological constructs. \u003csup\u003e3\u003c/sup\u003e,\u003csup\u003e27\u003c/sup\u003e,\u003csup\u003e28\u003c/sup\u003e,\u003csup\u003e29\u003c/sup\u003e,\u003csup\u003e30\u003c/sup\u003e Given that these constructs predict relapse, treatment adherence, and recovery trajectories, their systematic comparison between schizophrenia and BPAD in Indian settings remains critically under-examined. Understanding disorder-specific psychological vulnerabilities in this context is essential for designing feasible, culturally attuned psychosocial interventions within resource-limited mental health services. We designed this study to directly compare self-esteem and stress experiences between schizophrenia and BPAD in an Indian tertiary psychiatric setting.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eDesign and Setting\u003c/p\u003e \u003cp\u003eThis cross-sectional comparative study was conducted at a tertiary psychiatric facility serving predominantly rural populations in northern Karnataka, India. Data collection occurred between September 2024 and February 2025.\u003c/p\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003cp\u003eWe recruited 80 patients, 40 diagnosed with schizophrenia (ICD-11: 6A20) and 40 with bipolar I disorder (ICD-11: 6A60).\u003csup\u003e31\u003c/sup\u003e All were in partial remission, meaning acute symptoms had subsided, but complete recovery had not occurred.\u003c/p\u003e \u003cp\u003eInclusion required: confirmed diagnosis through clinical evaluation and medical records; age 18 years or above; willingness to participate. We excluded patients with comorbid substance dependence (except tobacco), organic brain disorders, or cognitive impairment preventing meaningful participation.\u003c/p\u003e \u003cp\u003eConvenience sampling was used; we approached eligible patients during their inpatient stay until reaching our target numbers.\u003c/p\u003e \u003cp\u003eMeasures:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eRosenberg Self-Esteem Scale (RSES):\u003csup\u003e7\u003c/sup\u003e A 10-item Guttman scale assessing global self-esteem. Responses range from \"strongly agree\" to \"strongly disagree.\" Scores are combined using a specific algorithm, yielding three categories: \u0026lt;15 (low), 15\u0026ndash;25 (normal), \u0026gt;\u0026thinsp;25 (high self-esteem).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePerceived Stress Scale (PSS):\u003csup\u003e10\u003c/sup\u003e,\u003csup\u003e32\u003c/sup\u003e A 10-item instrument measuring subjective appraisals of stress over the past month. Scores range 0\u0026ndash;40, categorised as low (0\u0026ndash;13), moderate (\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), or high (\u003cspan additionalcitationids=\"CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eScale for Assessment of Positive Symptoms (SAPS):\u003csup\u003e33\u003c/sup\u003e Evaluated positive symptom severity in schizophrenia across hallucinations, delusions, bizarre behaviour, and formal thought disorder.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eYoung Mania Rating Scale (YMRS):\u003csup\u003e34\u003c/sup\u003e An 11-item scale assessing manic symptoms in BPAD patients.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDemographic proforma: Collected age, gender, education, occupation, marital status, and illness-related variables.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e Procedures: Ethical approval was obtained from the institutional ethics committee (reference withheld for blind review). Trained research assistants administered assessments individually in private settings following written informed consent. Diagnoses were confirmed via clinical evaluation and medical records documentation.\u003c/p\u003e \u003cp\u003eStatistical Analysis: Descriptive statistics characterised the sample. Independent samples t-tests compared self-esteem and perceived stress between groups. Pearson correlations examined relationships between self-esteem and stress within each diagnostic group. Preliminary analyses controlled for age, gender, and illness duration. Significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSample Description\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarises participant characteristics. The groups were similar on most variables. One notable difference: more BPAD patients fell in the younger age bracket (95% aged 15\u0026ndash;47 years versus 80% of schizophrenia patients; χ\u0026sup2;=4.11, p\u0026thinsp;=\u0026thinsp;0.043).\u003c/p\u003e \u003cp\u003eBoth groups were predominantly rural (86% overall), Hindu (89%), and had limited formal education (only 9% held degrees). Most worked as farmers or daily wage labourers. The majority lived with family members.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSchizophrenia (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBPAD (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge 15\u0026ndash;47 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.04*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural Residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo formal Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e*p \u003c 0.05\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eMain Findings\u003c/h2\u003e \u003cp\u003eThe primary results were striking. Schizophrenia patients reported substantially lower self-esteem than bipolar patients (mean 18.45 versus 22.80; t\u0026thinsp;=\u0026thinsp;3.45, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The effect size was large (Cohen's d\u0026thinsp;=\u0026thinsp;0.77). Nearly three-quarters of schizophrenia patients (72.5%) fell in the low self-esteem range, compared with just over half (52.5%) of bipolar patients. (See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for detailed self-esteem and stress comparisons.)\u003c/p\u003e \u003cp\u003eStress showed the reverse pattern. Schizophrenia patients experienced significantly more perceived stress (mean 28.65 versus 23.10; t\u0026thinsp;=\u0026thinsp;3.82, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Again, the effect was large (d\u0026thinsp;=\u0026thinsp;0.86). Almost nine in ten schizophrenia patients (87.5%) reported moderate-to-high stress, versus two-thirds (65%) of bipolar patients.\u003c/p\u003e \u003cp\u003eWomen fared worse in both diagnostic groups. Female schizophrenia patients scored lower on self-esteem (mean 16.83 versus 20.94 for males; p\u0026thinsp;=\u0026thinsp;0.01) and showed similar patterns in BPAD.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelf-Esteem and Stress by Diagnosis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSchizophrenia\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBPAD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ed\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-esteem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.45 (5.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.80 (5.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived stress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28.65 (6.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.10 (7.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: Values are mean (SD). t\u0026thinsp;=\u0026thinsp;t-test statistic; p\u0026thinsp;=\u0026thinsp;p-value (significance level); d\u0026thinsp;=\u0026thinsp;Cohen's d (effect size). All comparisons were statistically significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Effect sizes (d\u0026thinsp;\u0026ge;\u0026thinsp;0.77) indicate large clinical differences between groups.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRelationship Between Self-Esteem and Stress\u003c/h3\u003e\n\u003cp\u003eSelf-esteem and stress were inversely related in both groups; lower self-worth accompanied higher stress. This correlation was strong in schizophrenia (r=-0.58, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and moderate in BPAD (r=-0.42, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The associations held after adjusting for age and gender. (See Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e for correlation data.)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelf-Esteem and Stress Correlation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchizophrenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBPAD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: r\u0026thinsp;=\u0026thinsp;Pearson correlation coefficient (ranges from \u0026minus;\u0026thinsp;1 to +\u0026thinsp;1; negative values indicate inverse relationships). p\u0026thinsp;=\u0026thinsp;probability value indicating statistical significance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicates the relationship is unlikely to be due to chance).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSecondary Analyses: Educational attainment showed protective effects in both groups: individuals with secondary or higher education reported higher self-esteem and lower stress compared to those with primary education only (schizophrenia t\u0026thinsp;=\u0026thinsp;2.87, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01; BPAD t\u0026thinsp;=\u0026thinsp;2.15, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Illness duration demonstrated no significant correlations with either outcome, contrary to expectations. Symptomatic severity (SAPS total scores in schizophrenia, YMRS in BPAD) showed moderate negative associations with self-esteem in schizophrenia (r = -0.44, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) but weak associations in BPAD (r = -0.18, p\u0026thinsp;=\u0026thinsp;0.26).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis comparative study documents significant psychological disparities between schizophrenia and BPAD in cross-sectional remission states. Individuals with schizophrenia experienced markedly lower self-esteem and elevated perceived stress compared to those with BPAD. These differences appear robust, with large effect sizes, and persist after controlling for sociodemographic variables.\u003csup\u003e24\u003c/sup\u003e,\u003csup\u003e25\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSelf-Esteem: A Trait Marker in Schizophrenia: The pronounced self-esteem deficits in schizophrenia align with literature indicating that low self-regard operates as a trait-like vulnerability in this disorder.\u003csup\u003e9\u003c/sup\u003e,\u003csup\u003e35\u003c/sup\u003e,\u003csup\u003e14\u003c/sup\u003e This pattern may reflect the cumulative impact of persistent cognitive impairment, prominent negative symptoms, and chronic internalised stigma.\u003csup\u003e12\u003c/sup\u003e,\u003csup\u003e13\u003c/sup\u003e,\u003csup\u003e36\u003c/sup\u003e The correlation between symptom severity and self-esteem, observed in this study, suggests that residual symptoms maintain self-worth erosion even during partial remission.\u003csup\u003e33\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eBy contrast, BPAD patients, despite comparable illness severity, retained relatively better preserved self-esteem.\u003csup\u003e15\u003c/sup\u003e,\u003csup\u003e37\u003c/sup\u003e This difference may reflect the episodic nature of BPAD, wherein periods of euthymia allow for psychological recovery and renewed self-affirmation.\u003csup\u003e38\u003c/sup\u003e,\u003csup\u003e39\u003c/sup\u003e The observed mood-linked variations in self-esteem (higher during euthymia compared to historical manic or depressive phases) support this interpretation.\u003csup\u003e40\u003c/sup\u003e,\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePerceived Stress: Chronic vs. Episodic\u003c/p\u003e \u003cp\u003eThe heightened stress perception in schizophrenia is consistent with the diathesis-stress framework, wherein genetic vulnerability interacts with environmental adversity to maintain psychosis risk.\u003csup\u003e41\u003c/sup\u003e,\u003csup\u003e18\u003c/sup\u003e,\u003csup\u003e19\u003c/sup\u003e Our participants, despite remission status, continued to report chronic stress, suggesting that stress sensitivity persists as a neurobiological and psychological feature of schizophrenia.\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe lower stress in BPAD, even with comparable clinical impairment, may reflect different mechanisms.\u003csup\u003e21\u003c/sup\u003e,\u003csup\u003e22\u003c/sup\u003e BPAD stress often co-varies with mood state; individuals in euthymic remission may experience reduced acute stressors and heightened coping capacity.\u003csup\u003e11\u003c/sup\u003e,\u003csup\u003e38\u003c/sup\u003e Moreover, the polarity-specific stress sensitivity in BPAD, whereby stress type (loss vs. achievement) determines episode polarity, may result in more contextually determined stress patterns compared to the global hyperarousal observed in schizophrenia.\u003csup\u003e21\u003c/sup\u003e,\u003csup\u003e23\u003c/sup\u003e,\u003csup\u003e42\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGender Considerations: Female participants across both groups reported lower self-esteem and higher stress.\u003csup\u003e24\u003c/sup\u003e This finding resonates with broader literature on gender disparities in mental health and reflects potentially compound effects of illness stigma, gender role expectations, and social marginalisation.\u003csup\u003e13\u003c/sup\u003e,\u003csup\u003e36\u003c/sup\u003e In India's sociocultural context, the intersection of psychiatric illness with gendered expectations may intensify self-devaluation and stress in women.\u003csup\u003e3\u003c/sup\u003e,\u003csup\u003e27\u003c/sup\u003e,\u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eClinical Implications: These findings underline the necessity for disorder-specific interventions.\u003csup\u003e24\u003c/sup\u003e,\u003csup\u003e14\u003c/sup\u003e,\u003csup\u003e38\u003c/sup\u003e For schizophrenia, integrating self-esteem enhancement into standard care via narrative therapy, identity work, or strengths-based approaches may yield significant benefits.\u003csup\u003e43\u003c/sup\u003e Addressing internalised stigma, as a key mediator of low self-esteem, warrants particular emphasis.\u003csup\u003e13\u003c/sup\u003e,\u003csup\u003e9\u003c/sup\u003e,\u003csup\u003e36\u003c/sup\u003e Similarly, stress management interventions, targeting both neurobiological dysregulation (via supported coping strategies) and psychosocial stressors (via family work or environmental modification), appear critical.\u003csup\u003e11\u003c/sup\u003e,\u003csup\u003e28\u003c/sup\u003e,\u003csup\u003e38\u003c/sup\u003e For BPAD, whilst self-esteem appears relatively less compromised, interventions should target the instability and contingency of self-worth, particularly the reliance on external achievement for self-validation.\u003csup\u003e37\u003c/sup\u003e,\u003csup\u003e16\u003c/sup\u003e Psychoeducation emphasising mood variability and its impact on self-appraisals may enhance psychological insight and reduce episode precipitation.\u003csup\u003e38\u003c/sup\u003e,\u003csup\u003e39\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eImplications for Asian Mental Health Services\u003c/p\u003e \u003cp\u003eThese findings carry particular significance for mental health service delivery in Asian settings, where resource constraints necessitate prioritising high-yield, low-cost interventions. Self-esteem and perceived stress assessments require minimal training, no specialized equipment, and can be administered by psychiatric social workers or nurses within existing consultation frameworks. Our data suggest that routine screening for these constructs during outpatient follow-ups could identify schizophrenia patients at heightened risk for relapse or disengagement, enabling targeted allocation of limited psychosocial resources. In India's context, where mental health services remain concentrated in tertiary centres with high patient volumes and limited counselling capacity, brief self-esteem and stress assessments offer a pragmatic triage mechanism. Furthermore, the gender disparities observed, with women reporting worse outcomes across both disorders, underscore the need for interventions that explicitly address the intersection of mental illness stigma with gendered social roles in South Asian families. Family psychoeducation programmes emphasizing these psychological vulnerabilities, rather than symptom management alone, may prove more culturally acceptable and effective in collectivist societies.\u003c/p\u003e \u003cp\u003eLimitations: This study was cross-sectional, preventing causal inference. Convenience sampling may introduce selection bias. The PSS and RSES, developed in Western contexts, may not fully capture culturally specific expressions of stress and self-worth in Indian populations.\u003csup\u003e44\u003c/sup\u003e Future longitudinal, multisite studies incorporating qualitative methods and culturally adapted instruments would strengthen findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIndividuals with schizophrenia experience significantly compromised self-esteem and heightened perceived stress relative to those with BPAD, even during comparable remission states. These psychological vulnerabilities warrant integrated attention within clinical care frameworks. Routine assessment of self-esteem and stress, coupled with targeted psychosocial interventions, offers promise for enhancing resilience and recovery outcomes in schizophrenia. The findings underscore the value of comparative approaches in unmasking disorder-specific psychological mechanisms and informing tailored, person-centred mental health care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclaration of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthor 1 conceived and designed the work, acquired, analysed, and interpreted the data, and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eAuthor 2 conceived and designed the work and provided critical revision of the manuscript for intellectual content.\u003c/p\u003e\n\u003cp\u003eAuthor 3 conceived and designed the work, provided critical revision of the manuscript for intellectual content, and gave final approval.\u003c/p\u003e\n\u003cp\u003eAll authors have approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2013. Ethical approval was obtained from the Institutional Ethics Committee (Ref: [withheld for blind review]).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: not applicable\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during the current study are available from the corresponding author upon reasonable request, subject to ethical approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTransparency Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe lead author affirms that this manuscript provides an honest, accurate, and transparent account of the study. No important aspects have been omitted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThesis Disclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was completed as part of the first author's MPhil dissertation at a tertiary psychiatric institution in India.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eThe World Health Organization. Mental health. Published 2021. Accessed July 23, 2025. https://www.who.int/health-topics/mental-health#tab=tab_1\u003c/li\u003e\n\u003cli\u003eMental GBD, Collaborators D. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990\u0026ndash;2019: a systematic analysis for the Global Burden of Disease Study 2019. \u003cem\u003eThe Lancet Psychiatry\u003c/em\u003e. 2022;9(2):137-150. doi:10.1016/S2215-0366(21)00395-3\u003c/li\u003e\n\u003cli\u003e\u0026Ccedil;ağlayan B, Dil S. 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The Mediating Effects of Self-Esteem and Resilience on the Relationship Between Internalized Stigma and Quality of Life in People with Schizophrenia. \u003cem\u003eAsian Nurs Res (Korean Soc Nurs Sci)\u003c/em\u003e. 2019;13(4):257-263. doi:10.1016/j.anr.2019.09.004\u003c/li\u003e\n\u003cli\u003eCoons MJ, Steglitz J, Division CP. \u003cem\u003eEncyclopedia of Behavioral Medicine\u003c/em\u003e.; 2013. doi:10.1007/978-1-4419-1005-9\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"self-esteem, perceived stress, schizophrenia, bipolar disorder, comparative study","lastPublishedDoi":"10.21203/rs.3.rs-9289386/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9289386/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAims and Method\u003c/p\u003e\n\u003cp\u003eSelf-esteem and perceived stress are significant psychosocial variables influencing outcomes in severe mental illness. Comparative research between schizophrenia and bipolar affective disorder (BPAD) remains sparse, particularly in Indian settings. We investigated whether self-esteem and stress perception differ between the two conditions. Eighty patients in partial remission (40 per diagnosis) were recruited from a tertiary psychiatric facility in India. Participants completed the Rosenberg Self-Esteem Scale and Perceived Stress Scale.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eSchizophrenia patients showed markedly lower self-esteem (mean 18.45 vs 22.80; t=3.45, p\u0026lt;0.001, d=0.77) and higher stress (mean 28.65 vs 23.10; t=3.82, p\u0026lt;0.001, d=0.86) than BPAD patients. Self-esteem and stress correlated strongly in schizophrenia (r=-0.58) and moderately in BPAD (r=-0.42). Women reported worse outcomes across both groups.\u003c/p\u003e\n\u003cp\u003eClinical Implications\u003c/p\u003e\n\u003cp\u003eSchizophrenia patients demonstrate persistent psychological vulnerability during remission. Integrating routine screening for self-esteem and stress difficulties with psychosocial interventions targeting self-worth and stress management alongside pharmacological treatment may enhance outcomes in schizophrenia.\u003c/p\u003e","manuscriptTitle":"Self-Esteem and Perceived Stress in Schizophrenia and Bipolar Affective Disorder: A Comparative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-27 06:00:46","doi":"10.21203/rs.3.rs-9289386/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ea80bc33-0cf2-47a2-bc42-b42461d7c4ac","owner":[],"postedDate":"April 27th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-04-30T21:39:38+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-30T21:54:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-27 06:00:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9289386","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9289386","identity":"rs-9289386","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}